Provider Demographics
NPI:1932635703
Name:THIELE, KRISTA RENEE
Entity Type:Individual
Prefix:MISS
First Name:KRISTA
Middle Name:RENEE
Last Name:THIELE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1363 DOUGLAS DR STE 104
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49696-8980
Mailing Address - Country:US
Mailing Address - Phone:231-668-4909
Mailing Address - Fax:
Practice Address - Street 1:3887 OKEMOS RD STE A1
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3663
Practice Address - Country:US
Practice Address - Phone:231-668-4909
Practice Address - Fax:231-943-1334
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician